Monday, April 11, 2005

I've been meaning to come back to the issue discussed in this post. In the comments, OneMan said this:

"My issue isn't really the drug, it's my fear that we are going to require medical professionals to be forced to turn off their own Moral judgments because the state says they will."

The way I read this, OneMan worries about pharmacists (and perhaps even doctors - more on that in a later post) being subjected to unwarranted government intrusion.

Perhaps we can find some common ground her, because my position on this comes from a very similar worry on the other side. I worry about patients being subjected to unwarranted intrusion into their health care by pharmacists.

It boils down to this question: how much power should a pharmacist - who did not go to medical school and is not a doctor - have over your health care? Pharmacists are trained (I assume) to understand drugs, side effects, and drug interactions. I'm sure this list is far from complete and I mean no disrespect to pharmacists, but I don't think they are necessarily qualified to diagnose medical problems. That's why they fill prescriptions, rather than write them.

By refusing to fill a prescription, a pharmacist is essentially usurping the role of the doctor. He is saying, in effect, that you don't really need that drug after all. His "diagnoses" is based entirely on his own opinion or whim, not any sort of objective criteria like a medical examination.

Frankly, as a patient, I would much prefer that doctors do the work of diagnosing my health issues, not the guy behind the counter at Walgreens.

Again, I remain fairly convinced that this sort of law would have been tossed out long ago if the drugs were something completely unconnected to sex, and even more so if they were drugs commonly used by men.

Lets take this to the logical extreme. A pharmacist we'll call "Bob" has a moral opposition to just about every imaginable drug. And so he spends his day behind the counter at Walgreens reading novels and turning away customers. Because he justifies this with proclamations that these drugs are immoral, Walgreens is prohibited from firing him.

Yes, that is a ridiculous scenario. But, what is the difference between believing that birth control is immoral and believing that anti-psychotic drugs used by schizophrenics are immoral? Answer: there is no difference. In both cases the pharmacist is relying on his own opinion and is using that opinion to overrule a doctor's recommended treatment.

If you believe that pharmacists have the right to use their own opinions of morality when choosing which prescriptions to fill, then you must allow that right to be applied to any drug, not just contraceptives. That is what I find terribly scary. This policy opens the door for strangers to meddle with my health care on very flimsy "morality" claims. Since a "personal moral judgment" is, well, personal, I cannot counter it with any objective claim. Any and every legal prescription drug is at risk under this kind of law.

For example, I have an uncle who is schizophrenic and the years he spent without medication are pretty much lost to him. Even with meds he is "not quite right," but at least he can function. His doctors monitor his condition and select the drugs that work for him. They are the ones who have examined him. It seems outrageous to me that some guy behind the counter at Walgreens should be allowed to overrule those doctors and deny my uncle his drugs just because their religious beliefs dictate that mental illness is a character flaw that can be cured by concentrating and praying real hard. They are entitled to those beliefs of course, and they can live their OWN lives in accordance with them. They just don't have the right to impose those beliefs on someone else.

Explain to me the difference between this scenario and the oral contraceptive scenario. Should the pharmacist be allowed to deny my uncle his drugs? If not, why is he allowed to deny a woman birth control? In some cases, both can be equally necessary for maintaining health (as I've mentioned many times before, birth control can be used for health issues that have nothing to do with preventing pregnancy).

Here's another example - let's say the pharmacist believes that AIDS is God's punishment for immoral behavior. As I recall from the 80's, this used to be a very common belief (and probably still is in some quarters). So, the pharmacist refuses to fill prescriptions for AIDS drugs, under the argument that combating the disease is thwarting God's plans for punishment.

Do you really think this is a good idea to give pharmacists such power? To let them be the gatekeepers who decide who gets their health problems cured and who doesn’t?

The argument that one could always go to a different pharmacy, or come back later, only works so well, particularly in an emergency situation. Where I live, sure no problem - there are plenty of other places nearby. In, say, rural Montana you might be talking about a 2-hour drive to the next major town. And then you have this situation, in which the pharmacist refused to transfer the contraception prescription to another pharmacy.

Finally, there is an argument that surely a free-market, business-friendly, capitalist Republican ought to agree with - what about the rights of the pharmacy or store itself? Stephen Chapman addressed this one in this column in the Chicago Tribune.

“Walgreens or Osco might rather put customer needs above the preferences of employees. But that choice is off the table. Under the conscience law, employers involved in health care can't discriminate against employees who refuse to do something they find morally objectionable.”

If I own a pharmacy, why should I be forced to keep an employee who turns away and alienates PAYING customers? The current law allows exactly that. This is strange because other jobs do not offer such blanket protection of personal morality. If the company for which I work asked me to do something that was completely legal, yet immoral in my mind, I could certainly refuse, but it is unlikely that I would keep my job.

Chapman's compromise, which I could sorta live with, is to let the pharmacies choose what drugs they will carry and require their employees to dispense them. Pharmacists who object to birth control can find jobs at pharmacies with the same philosophy. This doesn't seem to be an undue hardship for them -- the rest of us have to find some way to reconcile our livelihood with our own ethical principles. A committed vegetarian is unlikely to get a job working at a butcher. If he did, then refused to sell meat to paying customers, I don't think his employment would last very long. I think telemarketers are a scourge, so you will never catch me working for one. It would be absolutely ridiculous for me to get a job at a telemarketer, then refuse to call people on the grounds that I think it is wrong.

I personally believe that most pharmacies would choose the keep-our-customers-happy option over the turn-away-customers-and-piss-them-off option. This system would work even better if the stores advertised their respective policies up front. Even though I don't use any sort of contraception, I would make an effort to shop only at contraception-friendly stores on principle. Furthermore, this advertising would make it easy to know where to go (and where not to go) in the event of an emergency.

This obviously wouldn't help someone living in the boondocks somewhere if the only pharmacy in town was run by a fundamentalist Christian, so it isn't perfect, but it would certainly be better than the current system in which your healthcare is determined by who happens to be working current shift at Walgreens.

I have to admit, though, I still do not understand how dispensing drugs to a stranger can possibly be an affront to anyone's moral values. That is, I can certainly understand that an anti-contraception person would turn down such drugs herself. In the case of a man, perhaps he would insist that his wife not take them. That would be a matter for an individual couple to decide on their own. But how does it infringe upon that pharmacists rights for someone else -- like myself -- to take those drugs?

In his comment, OneMan also asked whether doctors should be required to write these prescriptions. I have thoughts on that issue as well, but I think this post is already too long, so I will address that issue shortly in another post.